Case Report
A 48-year-old man with history of tracheal squamous cell carcinoma and
completion of definitive chemoradiotherapy nine months prior presented
to an outside hospital with a three-day history of small-volume
hemoptysis and chest pain. Subsequent workup with computed tomography
revealed an aorto-tracheal fistula between the posterior aortic arch
(zone 1) and anterior surface of the distal trachea, with concomitant
tracheal stricture (Figure 1). His vital signs were within normal limits
and he was directly transferred to an operating room for emergency
surgical intervention.
The patient was intubated with a single-lumen endotracheal tube
following sedation and direct laryngoscopy. With bronchoscopic guidance
the endotracheal tube was positioned proximal to the stenosis to avoid
instrumenting the fistula. Flexible fiberoptic bronchoscopy then
demonstrated an irregular stricture involving the mid-distal
cartilaginous trachea with preservation of the membranous airway.
Immediately distal to the stenosis, a pit in the anterior trachea was
identified approximately 2 cm from the carina with associated bloody
mucoid secretions. Following placement of additional arterial monitoring
lines, central line, Swan-Ganz catheter, Foley catheter, and brain
function monitor (Masimo Corp., Irvine, CA, USA), an 8 mm right axillary
artery chimney graft was placed (Getinge AB, Göteborg, Sweden) via right
axillary cutdown. Placement of a transesophageal echocardiography probe
was attempted but resulted in extremely poor ventilation, likely
secondary to extrinsic compression from the probe onto the narrowed
trachea at the level of the stricture. Therefore, it was removed and
later re-introduced after initiating cardiopulmonary bypass. A median
sternotomy was then made; the incision was extended inferiorly into a
partial upper laparotomy. A two-stage venous cannula was inserted into
the inferior vena cava via the right atrial appendage. Following
systemic heparinization, the patient was placed on cardiopulmonary
bypass and cooled; an aortic root cannula, retrograde cardioplegia
cannula, and left ventricular vent were then placed. Simultaneously, a
pedicled omental flap was harvested.
The ascending aorta and aortic arch were next mobilized as the patient
was cooled to 24 degrees Celsius (bladder temperature). The aorta was
cross-clamped and the heart arrested with 1 L of antegrade Del Nido
cardioplegia. Selective antegrade cerebral perfusion was initiated at 10
cc/kg/min by clamping the innominate artery. The aortic cross-clamp was
removed and the proximal and mid aortic arch were excised, most
aggressively along the lesser curve and slightly posteriorly into the
arch, so that the fistula defect was incorporated into the resected
specimen. The tracheal defect thereby came into view immediately
posterior to the resected transverse arch. At this point only a
peninsula of greater curve remained, which contained the innominate and
left common carotid artery takeoffs. The distal extent of the
lesser-curve resection was between the level of the left common carotid
and left subclavian arteries. To fully visualize the tracheal defect,
the innominate artery was sharply detached from the remaining greater
curve.
The trachea was carefully inspected. There was extensive fibrosis
related to prior therapy, as well as fibrinous material consistent with
a subacute inflammatory process. After limited debridement of scar and
devitalized tissue, a 3 mm airway defect was defined. Primary repair was
not possible due to tissue loss and fibrosis, thus an overlay patch
repair was performed. Horizontal mattress sutures were placed
circumferentially around the defect using 4-0 PDS. A portion of
autologous pericardium, harvested earlier in the case and placed in
saline, was folded and trimmed to form a double-layer pericardial patch.
This patch was then parachuted-down using the horizontal mattress
sutures to rapidly provide an initial scaffold for repair before
replacing the aorta and compromising exposure (Figure 2).
An open distal, zone-1, anastomosis was then performed using a 26 mm x
10 mm x 8 mm x 8 mm x 10 mm multi-branch graft (Getinge AB, Göteborg,
Sweden). Antegrade flow was then reestablished via sidearm perfusion;
the proximal graft-to-native ascending-aorta anastomosis was then
performed, after which the aortic cross-clamp was removed and the
innominate artery was anastomosed to one limb of the multi-branch graft
(the unused limbs were ligated) (Figure 3).
The tracheal repair was completed during rewarming. The aortic graft was
carefully retracted, the field was flooded with saline, and ventilation
commenced to assess air leak. The edge of the patch was reinforced with
a continuous running 4-0 PDS suture and several targeted horizontal
mattress sutures until complete pneumostasis was achieved. Progel
sealant (BD, Franklin Lakes, NJ, USA) was applied to reinforce. Once the
patient had rewarmed to 36 degrees Celsius, he was successfully weaned
from cardiopulmonary bypass and hemostasis achieved. The greater omentum
was liberated from the transverse colon, rotated on the gastroepiploic
pedicle, and secured to the repair to provide vascularized tissue
between the tracheal repair and the aortic graft.
The patient was extubated on post-operative day 1; the remainder of his
hospitalization was notable for reintubaton for aspiration pneumonitis
on post-operative day 6, as well as gastric outlet obstruction
necessitating open revision of his omental flap on post-operative day
22. He was ultimately discharged to a rehabilitation facility on
post-operative day 38. He made a satisfactory recovery thereafter and
was alive and neurologically intact as of 13 months post-operatively.